NRSG 121 - Exam 1 EAQ

A nurse is assessing a patient's hearing ability. Which findings would indicate compromised hearing? - The patient is lip reading The patient asks to have certain words repeated The patient fails to respond to questions when not looking directly at the nurse The nurse is performing an assessment of a patient's ear with an otoscope and finds that the light reflex is fuzzy. How does the nurse interpret this finding? - Retraction of the tympanic membrane A patient is due for rotary chair testing to assess vestibular function. What action by the nurse is most appropriate? - Observe the patient for vomiting Rotary chair testing - Done to evaluate the peripheral vestibular system. Testing is usually done in the dark; therefore, in order to ensure safety, the nurse should not leave the patient alone. The patient should be advised to eat a light meal before the test to avoid nausea. The nurse should monitor the patient for vomiting. The length of the test is not relevant. The nurse is testing a patient for hearing acuity using a whisper test. Which actions by the nurse are appropriate? - After exhaling, speak in a low whisper Ask the patient to repeat numbers or words Whisper loudly if the patient does not respond correctly Testing hearing acuity - The nurse should stand 12 to 24 inches to the side of the patient and, after exhaling, speak in a low whisper. Ask the patient to repeat numbers or words or answer questions. Use a louder whisper if the patient does not respond correctly. Test each ear separately. The ear not being tested is covered by the patient. A patient seeks assistance from the primary health care provider because of episodes of vertigo. Which diagnostic test will determine whether the vertigo is related to a problem of the inner ear? - Caloric stimulus test Caloric stimulus Test - Cold or warm water is inserted in the ear canal to stimulate the semicircular canals in the labyrinth of the inner ear. The response to the stimulation causes nystagmus (eye ball jerking movement), nausea and vomiting, and vertigo, and is used to determine disease of the vestibular system. Vertigo - Is the sensation that one is whirling in space and often is associated with nausea and vomiting. Audiometry - Is a screening test for hearing acuity and determines the severity and type of hearing loss. Tympanometry - Is used to diagnose middle ear effusion (fluid in the middle ear), which causes noncompliance and conductive hearing loss. When interviewing a patient with hearing loss about past and present medications, which medications should the nurse ask the patient about directly? - Salicylates Aminoglycosides Antimalarial agents The nurse should ask the patient specifically about salicylates, aminoglycosides, and antimalarial agents, because they may cause ototoxicity and lead to hearing loss. The nurse is interviewing a patient diagnosed with glaucoma. What question is most relevant to the patient's condition? - Do you have a history of cardiac or pulmonary disease? Why is it important to ask patients with glaucoma about history of cardiac or pulmonary disease? - Glaucoma is often treated with beta-adrenergic blockers, which may decrease heart rate, decrease blood pressure, and exacerbate asthma or chronic obstructive pulmonary disease (COPD). The nurse is assessing a patient's ears. What normal findings should the nurse document? - TM is pearly gray, shiny and translucent The handle of the malleus and its short process are visible through the TM The TM is concave or dome shaped normally A nurse is assessing the pupillary function of a patient. Which steps should be performed when assessing accommodation? - Ask the patient to look at the nurse's finger Ask the patient to focus on a distant object The nurse places a finger at a distance of 3 inches from the patient's nose Auditory evoked potential - Is conducted in a darkened room and electrodes are placed over the mastoid process, vertex, and forehead to isolate auditory activity from other activities. Electrocochleography - records electrical activity in the cochlea and auditory nerves Electronystagmography - in which specific eye movements are recorded, is used to diagnose diseases of the vestibular system. Ototoxic drugs - aspirin chemotherapy drugs antibiotics antimalarial drugs NSAIDs diuretics